to determine clinical variables that can predict the need for division of the short gastric vessels (SGV), based on the gastric fundus tension, assessing postoperative outcomes in patients submitted or not to section of these vessels.

METHODS:

we analyzed data from 399 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease (GERD). The section of the SGV was performed according to the surgeon evaluation, based on the fundus tension. Patients were divided into two groups: not requiring SGV section (group A) or requiring SGV section (group B).

RESULTS:

the section was not necessary in 364 (91%) patients (Group A) and required in 35 (9%) patients (Group B). Group B had proportionally more male patients and higher average height. The endoscopic parameters were worse for Group B, with larger hiatal hernias, greater hernias proportion with more than four centimeters, more intense esophagitis, higher proportion of Barrett's esophagus and long Barrett's esophagus. Male gender and grade IV-V esophagitis were considered independent predictors in the multivariate analysis. Transient dysphagia and GERD symptoms were more common in Group B.

CONCLUSION:

the division of the short gastric vessels is not required routinely, but male gender and grade IV-V esophagitis are independent predictors of the need for section of these vessels.

Laparoscopic total fundoplication is an effective procedure for the treatment of gastroesophageal reflux disease (GERD)1. However, some technical points are still controversial, especially the need for short gastric vessels (SGV) division2. While most authors believe this step brings better results3-5, others showed similar outcomes whether SGV are divided or not or even complications attributed to SGV division2,6-9.

This study aims to determine: (a) clinical variables that may predict the need of SGV division based on gastric fundus tension and (b) the outcomes in patients with or without SGV division.

METHODS

We retrospectively studied 399 consecutive patients (50% male, mean age 49 years) recorded in a prospectively kept database that underwent laparoscopic total fundoplication for the surgical treatment of GERD. This study was approved by the local institutional review board. (CEP 0742/11).

Patients were questioned before the operation regarding the presence of symptoms. These were grouped into esophageal symptoms (heartburn and regurgitation), extra-esophageal symptoms (thoracic pain, respiratory symptoms, such as cough and asthma or ear, nose and throat symptoms) or dysphagia. Anthropometric variables were also recorded. Individuals with partial fundoplication, paraesophageal hernia, previous foregut operation or conversion to conventional laparotomy were excluded from the analysis.

All patients were submitted to an upper endoscopy to evaluate the presence of hiatal hernia (HH), esophagitis and Barrett´s esophagus. HH was classified according to size in <4cm or >4cm. Modified Savary-Miller endoscopic classification10 was used for grading esophagitis. Barrett esophagus was defined by the presence of intestinal metaplasia and classified as short-segment (<3cm) or long-segment (>3cm). Esophageal manometry was available to review in 283 (71%) patients. Ambulatory 24-hour esophageal pHmonitoring was only performed in patients without esophagitis or with atypical symptoms. pHmonitoring results were available for review in 62 (15%).

Surgical technique has been previously described2. In summary, an extensive mobilization of the posterior wall of the gastric fundus followed the dissection of the distal esophagus and diaphragmatic crus in all patients. SGV division was done at the discretion of the surgeon based on tension of the gastric fundus after performing a specific maneuver ("drop-test" - Figure 1). A short-floppy total fundoplication was performed without the aid of a bougie. All procedures were performed by or under the supervision of a single experienced surgeon. Patients were grouped according to the necessity for SGV division (Group A - no division; Group B - SGV division).

Figure 1 - Gastric fundus in place without the need of traction - drop-test- (Arrows).

Follow-up visits were scheduled for 15, 30, 90, 180 and 360 days after the surgery and then annually, irrespective of the presence of symptoms. Upper endoscopy was performed annually or earlier if the patient had any complaints related to the postoperative period. All selected patients had at least a 6-month postoperative follow-up period.

Chi-square, Student's t test and logistic regression were used when necessary. A value of p was considered significant at the 0.05 level. Variables are expressed as mean ± standard deviation.

Table 2 - Multivariate analysis for the need to short gastric vessels division.

Variable

Odds Ratio(95% CI)

P Value

Male gender

28.3

(2.25-355.22)

0 . 0 1 0

Weight

1.03

(0.98-1.09)

0.216

Hiatal hernia length

1.64

(0.75-3.59)

0.213

Esophagitis grade IV-V

19.5

(2.08-182.26)

0 . 0 0 9

Barrett esophagus and extension

0.11

(0.01-1.06)

0.056

LES pressure

0.79

(0.62-1.01)

0.063

LES, lower esophageal sphincter; CI, confidence interval.

Average follow-up was 13.8 months. Outcomes at last follow-up are depicted in table 3. Transient dysphagia and GERD symptoms were more common in Group B.

Table 3 - Clinical follow-up.

Variable

No SGV division

SGV division

P

n = 3 6 4

n = 3 5

Transient dysphagia

6

(1.6%)

4

(11.4%)

0 . 0 0 7

Persistent dysphagia

12

(3.3%)

1

(2.8%)

1

Reflux symptoms

6

(1.6%)

3

(8.5%)

0 . 0 4

Subgroup analysis

Variable

Male sex. esophagitis IV-V,

Other patients

P

no SGV division

n = 3 4 1

n = 5 8

Transient dysphagia

4

(6.9%)

8

(2.3%)

0.08

Persistent dysphagia

1

(1.7%)

11

(3.2%)

1

Reflux symptoms

1

(1.7%)

8

(2.3%)

1

SGV: short gastric vessels.

If patients at higher risk for gastric fundus tension (namely males with severe esophagitis) that did not underwent SGV division are compared to the remaining patients no difference in symptoms were noticed.

DISCUSSION

Our results show that: (a) male gender and severe esophagitis are independent predictors for the need to SGV division and (b) SGV division may lead to more transitory dysphagia and GERD symptoms.

The effect of SGV division on the outcomes of laparoscopic fundoplication have been evaluated in five prospective randomized studies2,6-9 and their meta-analysis11-14. These studies showed a longer operative time and intraoperative bleeding2,6,8,9,11-14, higher incidence of transient dysphagia2 and gas-bloating syndrome7 when SGV are divided. Our results also showed more postoperative GERD symptoms. No benefit has been attributed to SGV division15. Very interestingly, however, authors that do not routinely divide SGV find this step necessary at the time of the fundoplication due to tension on the gastric fundus in up to 33% of patients16 even after extensive gastric fundus mobilization by lysis of adhesions between the stomach and diaphragm2,6.

In this study, 8.8% (35/399) of the patients needed SGVD for the completion of a short floppy fundoplication. The likely cause of this low need of SGVD is the extensive gastric fundus mobilization employed in all patients, as advocated by Farah et al2 and Chrysos et al6. We believe that when this surgical step is used, one makes a larger length of the gastric fundus available for the construction of a floppy fundoplication around the esophagus. So, even in those cases in which there is an enlarged cardia, this maneuver lessens the likelihood of the need of SGVD.

Some previous studies attempted to identify anatomic parameters to predict gastric fundus tension and consequent need to SGV division. Szor et al.16 found some sort of tension in half of the cases during fundoplications in cadavers, but no anatomic parameter predicted this tension. Huntington et al.17 deemed necessary to divided SGV in some patients based on the gastric fundus length and the esophageal circumference. Severe esophagitis as a predictor for fundus tension in our study may be linked to esophageal circumference as progressive dilatation of the esophageal diameter is observed as esophagitis severity increases18,19. Male gender may bring a higher chance of fundus tension probably due to more exuberant visceral fat compared to females. To the best of our knowledge, no other series studied clinical parameters to predict gastric fundus tension.

The current study studied a large number of patients; however, it has the limitations of a retrospective case series. As such, some parameters that could help understand the results of the study were not evaluated, such as the amount of visceral fat. Also, the time of follow-up is short for a stronger conclusion that SGV division does not affect long-term outcomes. More importantly, even though a single surgeon operated all cases, gastric fundus tension was based on subjective parameters.

We conclude that SGV division is not necessary routinely but male sex and grade IV-V esophagitis are independent predictors of the need of SGV division. However, not all patients in these conditions need SGV division as a subanalysis of these population that did not underwent this step did not show worse outcomes compared to other patients. Gastric fundus tension must still be evaluated based on subjective parameters by experienced surgeons.

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